Inspection on 20/07/05 for Bradbury House, Brislington

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bradbury House, Brislington 12/06/07

Bradbury House, Brislington 30/11/05

Bradbury House, Brislington 02/11/04

Bradbury House, Brislington 06/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Bradbury House & West Town Lane 14 Fairway Brislington Bristol BS4 5DF Lead Inspector Sarah Webb Unannounced 20 July 2005 9:30am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 3 SERVICE INFORMATION Name of service Bradbury House & West Town Lane Address 14 Fairway Brislington Bristol BS4 5DF 0117 9716716 0117 9853092 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Neil Bradbury Ms Michelle Hole PC Care home 15 Category(ies) of LD Learning disability (15) registration, with number MD Mental Disorder (3) of places Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 4 SERVICE INFORMATION Conditions of registration: Can accommodate up to 15 persons aged 18 - 65 years with learning disabilities. May accommodate up to 3 persons with Learning Disabilities and Mental Health needs. Date of last inspection 8 February 2005 Brief Description of the Service: Bradbury House and West Town Lane are registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to fifteen persons with a learning disability, aged 18-64 years of age. Primarily the service seeks to accommodate service users with autistic tendencies who may exhibit challenging behaviour. There is a condition of registration in that West Town Lane may accommodate up to 3 people with a learning disability and mental health need. Bradbury House is a listed building which is set back from the road in a quiet residential area. Within the grounds is a detached day care facility (the workshop), which is primarily accessed by the service users from Bradbury House. West Town Lane is a four-bedded property and is situated on the same site but is completely detached from Bradbury House. The service is managed by Ms Michell Hole who is registered with the Commission for Social Care Inspection. Mr N Bradbury owns Bradbury House and is the registered provider Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and was carried out as an unannounced inspection. This was the first inspection of both Bradbury House and 13 West Town Lane since the 2 properties came under the same registration. Since the last inspection there is a new manager in place; Michelle Hole has successfully completed a Fit Persons Interview and is now the registered manager of this service. The inspection methods used included record checks, case tracking, incident reports, regulation 37 reports and discussion with both the registered manager and the day service manager. Individuals receiving a service were met during a tour of both properties and during the midday meal. It was not possible to seek the full views of individuals as many of the people living at the home are unable to articulate using verbal communication. Staff were observed over the lunchtime period. What the service does well: What has improved since the last inspection? The environment has improved considerably taking into consideration both individual choices and health and safety. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 6 Staff have been trained in relation to individuals mental health needs. The home has purchased an additional medicine cabinet for storage of surplus stock. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 The assessed needs of individuals are met and there are processes in place for the admission of new service users. Staff have received appropriate training in order to meet the specific needs of individuals living at the home. The home meets the needs and preferences of the individual residents through both review and consultation procedures. EVIDENCE: There have been no new admissions since the last inspection. The home has an admissions policy and there are procedures in place for assessments to be carried out for prospective service users. The manager said discussion also takes place with all parties concerned in order to gain the appropriate information to make a decision as to whether the home can meet their needs. As at the previous inspection, it was evident that the home obtains a copy of the funding authority’s care plan, which in turn informs and supports the home’s care plan. It was evident that the home is meeting the care needs of the individuals; this was demonstrated through care planning and the home’s system of review. The home also works closely with specialist services in order to support individuals and offer advice to staff. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 There is a clear and consistent care planning system in place to adequately provide both residents and staff with the information they need to satisfactorily meet individual needs. The home encourages individuals to make decisions regarding their lifestyle. The home has risk management procedures in place to ensure residents are supported safely in taking risks. EVIDENCE: The home has continued to review individuals care plans on a 6 monthly basis. Those care plans observed were all up to date and had been reviewed, signed and dated. This is good practice. There was comprehensive information available for staff in order to meet needs of individuals; this included behavioural aspects/triggers points and diffusing techniques, risk assessments, timetables and programmes, Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 10 medication, life skills record, incident reports, monthly health checks, monthly keyworker reports. The manager said individuals are encouraged to make decisions with regard to their lifestyle and their environment. An individual said she had chosen the colour of her bedroom. A central communication board in the office recorded individuals’ daily choice of activities. Records also evidenced how staff support those who have non verbal communication. The home has a financial policy and includes procedures for the sake keeping of individuals’ finances. Risk assessments had been completed and reviewed on a regular basis. There were risk assessments in place for those individuals who presented behaviour that challenges- these were also linked into the care planning system. Risk assessments were in place for accessing bedrooms and the use of keys. There are no individuals who have a key to the front door. The manager said she had tried to work with an individual to have own key but was unsuccessful. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, & 17 The home offers opportunities for individuals to take part in appropriate social and educational opportunities in order to enhance their lifestyle. The meals in the home are good offering both choice and variety. EVIDENCE: Various activities are offered to individuals in both the local and external communities during the course of the week. Documentation observed, through the day diary and individuals records, included visits to shopping and leisure centres, farms, and parks and various trips to local areas of interest. Evening outings consist of visits to both local and country pubs, cinema, and bowling. A workshop on site that is included in the service for individuals living within the Bradbury organisation, also offers choice of planned activities and course to suit peoples needs. All courses are affiliated through Filton College. The manager said holidays have taken place; a group holiday to Wales and individual holidays to locations such as Blackpool, Minehead and Centre Pacs. The residents living in West Town Lane mostly use public transport. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 12 Transport is provided through the home for those needing support. It was evident through observation of the menu and sharing a midday meal with individuals that the home provides meals of a high standard. A cook is employed and individuals access three meals a day. Bradbury House & West Town Lane Version 1.30 D56_26526_BradburyHouse_236773_180705_Stage4.doc Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Individuals are supported well with their health care needs. The home has improved in the recording of the administration of medication to individuals ensuring that they are not put at risk. EVIDENCE: Two people have been admitted to hospital since the last inspection. The Commission for Social Care Inspection has been notified through regulation 37 reports. It was evident through documentation that individuals have access to health related professionals. Records indicated regular visits to appropriate health professionals and support to attend an annual health check. The home has a medication policy and procedure. The home has complied with a requirement for the home to obtain a new medication cabinet for surplus medication. Documentation seen relating to the administration of medication evidenced that the home has appropriate records in place. The home receives an annual inspection from the pharmacy, and the manager of the home and the day services manager have also received medication training through the pharmacist. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 14 This is then cascaded to the care staff who receive medication training 6 monthly; this was evidenced by records. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has procedures in place to consult with both staff and individuals regarding concerns and complaints. The home ensures the safety and protection of individuals through appropriate measures. EVIDENCE: The home has a complaints policy setting out the procedure to take including action to be taken and timescales to respond to any complaint. The home’s complaints procedure for individuals has been produced in an accessible format. There are processes in place for both staff and individuals to air their views and concerns. There have been no complaints since the last inspection. A neighbour has shown their concern to the home regarding noise level in a garden area. Through discussion with the manager it is evident that the home has tried hard to maintain a neighbourly approach and deal with this concern. The home has a policy for the protection of vulnerable adults. Staff are trained internally through the organisation’s NAPPI trainer in awareness of the protection of vulnerable adults. This was evidenced through observation of training records. The trainer has attended appropriate training himself regarding the protection of vulnerable adults through both the local authority and NAPPI. Although the manager is aware of the process regarding the reporting of an incident of abuse, she has booked to attend the investigatory training through Bristol Social Services. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 16 Documentation in place evidenced that staff have been police checked through the Criminal Records Bureau. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, & 30 The home makes great efforts to provide a homely environment whilst considering the health and safety needs of individuals. The home would benefit from a maintenance plan to ensure the consistency of redecoration and refurbishment. EVIDENCE: It is evident that both homes respect the need for individuals’ environment to be homely. The manager explained that the safety needs of individuals have to be considered. It was evident that the homes have had to be creative in providing both a homely and safe environment for individuals to live in. It was evident that there are still some areas that are in need of redecoration. An audit has been carried out on the maintenance needs of both homes. It was evident that the home has committed itself to improving the environment for the individuals living there. Since the last inspection, wooden flooring is in now in place in communal areas of Bradbury House. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 18 There are sufficient bathing facilities at both homes. Bathroom doors were lockable which can be overridden by staff if needed. Redecoration and refurbishment has taken place in a bathroom at Bradbury House while the lounge in West town Lane has also been redecorated. An individual said they were involved in choice of decoration and refurbishments. They also said they had chosen a new carpet in their bedroom. It was evident that all bedrooms have been decorated specifically for individuals. The home is looking for a new maintenance person to complete areas of redecoration. The home was clean and employs a cleaner during weekdays on a daily basis. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 & 35 The home needs to set out an action plan for the training of staff in relation to the National Vocational Qualification The home provides new staff with a clear induction process. The home has well documented recruitment procedures in order to ensure the safety of individuals. EVIDENCE: Currently there are no care staff that have been registered for a National Vocational Qualification. The manager explained verbally how the home is to approach the need for all staff to be qualified through a National Vocational Qualification. A requirement is unmet from the last inspection of West Town Lane for an action plan to be sent to the Commission for Social Care Inspection as to how this will be met. This requirement is carried through to this inspection. There are currently no staff vacancies. Through observation of the rota, it was evident that there is sufficient staffing on duty both during the day and night at both homes. Newly appointed staff undergo an induction process. This was evidenced through induction checklist. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 20 It was evident through documentation that staff are up to date with first aid and food hygiene training. Currently no staff have attended manual handling training. The manager said individuals have not needed support with their mobility in the past. A requirement made through this inspection for staff to attend manual handling training has been withdraw as this was specific to an individual and is no longer appropriate. However, following discussion with the manager, a requirement has been made for the home to keep the manual handling needs of individuals under review via risk assessments; should individuals needs change regarding their mobility or any other specific need where staff may need to offer physical support in their moving and handling, then appropriate manual handling training will need to be provided. All staff are working towards LDAF- 5 have completed Induction while 8 staff have completed Foundation Another manager in the organisation is responsible for training all staff in the organisation in relation to NAPPI. There were records of training completed and when up dates are required. Staff have also attended Mental Health awareness training. Staffing files observed included 2 references, CRB check, identity and other relevant documentation in place to evidence that the home has procedures in place to ensure the protection of individuals. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41, & 42 There is a clear management structure in place providing staff with support needed to carry out their duties and responsibilities. The home needs to improve fire procedures in order to ensure the health and safety of both staff and the individuals living at the home The home needs to ensure appropriate health and safety recording and documentation is in place. EVIDENCE: The manager has recently been registered through the Commission for Social Care Inspection. She has previous experience in working with adults with learning disabilities and has worked at Bradbury House for 3 years. She is in the process of completing National Vocational Qualification level 4. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 22 The day services manager and also the Area manager are registered for National Vocational Qualification level 4. The manager said progression to the assessors award is planned and the registration of staff for level 3. Records seen during the inspection include risk assessments, regulation 37 reports, service users finance and medication. The home sends incident forms to Commission for Social Care Inspection on a consistent basis informing the Commission of any restraint used. These were discussed in detail with the manager. There was a current certificate of insurance in place. Gas Safety certificate safety record was seen; however there was no electrical installation certificate available. The management team are responsible for individual health and safety issues such as fire and control of substances hazardous to health. It was evident through the fire safety log that fire training, fire drills and checks on the fire equipment have taken place at Bradbury House. However there was no record of fire drills for West Town Lane. Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 x x 3 Standard No 11 12 13 14 15 16 17 x 4 3 x x x 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bradbury House & West Town Lane Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 2 x D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 35 Regulation 18 Requirement Set out how the home intends for staff to be trained through the national vocational qualifications system Keep the manual handling needs of individuals under review via risk assessments; should individuals needs change regarding their mobility or any other specific need where staff may need to offer physical support in their moving and handling ,then appropriate manual handling training wil need to be provided. Ensure staff attend fire drills at West Town Lane Keep a record of fire drills and the names of staff who attend Timescale for action 30/11/05 2. 35 18 31/1/06 3. 4. 5. 42 41 23(4) 17(2) As from 20/7/05 As from 20/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 42 Good Practice Recommendations Provide the Commission for Social Care Inspection with a D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 25 Bradbury House & West Town Lane 2. 24 copy of the current 3 yearly electrical test that has been completed on the wiring of the home. Set out a maintenance plan for the redecoration of both homes Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 26 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bradbury House & West Town Lane D56_26526_BradburyHouse_236773_180705_Stage4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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